Promises, Promises

Medicaid's spreading sickness

It's too easy to criticize Idaho's Department of Health and Welfare. Taking shots at the state's largest agency is like shooting fish in a barrel. So, you may have dismissed the department's latest Medicaid debacle as another example of a dysfunctional tangle of red tape.

But a closer look reveals a massive breakdown of systems, communications, bookkeeping and a possible violation of HIPAA privacy rules, dangerously putting confidential patient information in the wrong hands.

The history of Idaho's Department of Health and Welfare pre-dates statehood. It was in the late 19th century that the first soldiers' home and insane asylum were built. State hospitals followed soon after, and in 1907 the Idaho Legislature created the State Board of Health, thus beginning a legacy of care.

Simply put, children have been protected, homeless have been sheltered, hungry have been fed and lives have been saved because of Health and Welfare. For more than a century, thousands of dedicated state-employed caregivers have given their all to the people of Idaho, from the first nurses at the original soldiers' home to today's caseworkers at service centers across the state.

But 2010 has been "annus horribilis" for the agency. Director Dick Armstrong set the pace in January, predicting office closures, layoffs and compromised service levels. In short time, Armstrong's prophecy became reality. To finish fiscal year 2010 with a balanced budget, the agency ordered more than 100 hours of unpaid furlough for all employees, shut down nine field offices and eliminated 125 positions.

"I respect the people who work there," said Boise Democratic Sen. Elliot Werk. "Most are underpaid, and they operate on a shoestring. Having said that, when you pay poorly, you'll get poor services."

The current Health and Welfare spending plan approaches $2 billion, and of that, $1.5 billion represents Medicaid (insurance coverage for the poor, disabled, elderly, children and pregnant women). There are more than 14,000 providers across Idaho that accept Medicaid coverage, in spite of its unpredictably. Since the fiscal year began on July 1, none have been sure when, or even if, they'll be paid for services rendered. But it's not for lack of promises.

In early spring, recognizing that state funds were running dry, Health and Welfare mailed out an unprecedented letter to each Medicaid provider in Idaho. Simply put, the letter was an I.O.U. Hospitals, doctors, nurses, counselors and thousands of their brethren were told that they would not be paid for three weeks in June, but they would receive retroactive funds when the new fiscal year began. Providers begged their landlords and creditors to be patient, and many even used the letter as proof that payment would be forthcoming.

"We had already negotiated with our landlord to work out payment arrangements," said Linda Lester of Tidwell Social Work in Boise, "and we had to ask our nine therapists to be patient."

Tidwell Social Work provides individual and group psychotherapy to about 150 clients, many of them refugees.

"As Boise's refugee community has grown, so has our client base," said Kathy Tidwell, who began her company 10 years ago. "Many of our clients have suffered severe trauma through war, refugee camps and relocation to a new world."

Tidwell estimates about 65 percent of her clients are Medicaid eligible, putting her company in a very vulnerable state.

But another Medicaid storm was brewing on the horizon. Health and Welfare had entered into a new business relationship with California-based Molina Healthcare to administer Idaho's Medicaid reimbursement system. In fiscal year 2009, Molina reported more than $3.6 billion in premium revenues. Idaho providers were notified of the change last October and were promised that the transition would be relatively transparent.

But right about July 9, the house of cards that is Idaho's Medicaid system began to fall.

"First, nothing showed up in our bank account. Then, nothing showed up in the mail," said Lester. "Then, we tried calling Molina."

"I've spent up to two hours a day on the phone trying to get through to Molina," said Linda Brock, Tidwell's office manager. "And when I did get through, I got a recorded message telling me to go to their website. But there's no information on the Web."

"That's exactly what we're hearing from our members," echoed Susie Pouliot, CEO of the Idaho Medical Association. Thousands of Idaho physicians are IMA members and most are Medicaid providers.

"Right now, the association is serving as a clearinghouse for our physicians. We centralize their concerns and advocate for them collectively," said Pouliot.

Medicaid representatives made a point of addressing IMA's board in person. IMA has even had some luck in getting through to Molina.

"We've scheduled a formal conference call to include our members, Molina and state Medicaid officials." Pouliot said the call should occur within the next week. Pouliot added that in the meantime "members have been experiencing a major cash flow issue."

But to hear it from Health and Welfare, the glass is half-full.

"In the grand scheme of things, the system is working, and it's paying out claims," said Emily Simnitt, public information officer for Health and Welfare. "I can tell you that there have been issues, and Molina is making adjustments. There are constant communications and we're working together."

Simnitt said if you follow the money, it appears as if the reimbursements are indeed becoming more current.

"In an average week, about $24 million in claims are processed. And I can tell you that so far in July, Molina has processed $120 million, so it sounds like things are improving."

Simnitt also said that an extra-big check was sent out to many Medicaid providers last week. Health and Welfare officials huddled with Molina and decided to send a check representing 80 percent of a typical month­--they chose April--minus any reimbursements that may have been recently sent to the provider.

That's news to the folks at Tidwell Social Work. BW paid another visit to their offices after talking with Simnitt.

"Nope, we haven't received that check. We're checking the mail every day," said Lester. "But the good news is we have received some money."

Tidwell has received a total of five checks in the past month. That's the good news. The bad news is that they have no idea what the money is for.

"We're not able to reconcile any of these amounts," said Brock. "There is no accompanying detail with the checks, and we simply don't know who's been paid for what." Pouliot said that's a common complaint from her members as well.

"We are aware of that problem, and we're working with Molina for a resolution," said Simnitt. "Our first priority was to get payments sent."

When we asked if the Medicaid headache had become a public-relations nightmare for the agency, Simnitt paused.

"I don't know how to answer that." She thought for a moment. "These are difficult times."

Still another problem surfaced just as BW was going to press--a problem that compromises the very system that protects a patient's right to privacy.

"We got a phone call from a provider in Idaho Falls," said Lester. "They told us they received a copy of detailed Medicaid reimbursements, listed by patient. But they were our patients, and a few days later, we received a list of patient information that belonged to another physician here in the Treasure Valley. That could be a pretty big HIPAA violation."

"Our Medicaid division administrator is aware of that problem as well," said Simnitt. "It was human error, not a system issue. We don't think it was a HIPAA violation."

HIPAA is the Health Insurance Portability and Accountability Act, designed to protect individually identifiable health information.

And according to the U.S. Dept. of Health & Human Services, HIPAA must protect "billing information about you at your clinic," even when a provider "uses a billing service or third party to do so on its behalf."

So how are therapists at Tidwell holding up?

"We've paid them some amounts of money," said Lester. "If we hadn't dipped into our own personal reserves, we would have had to close our doors."

Lester also said that one therapist had to go part-time, just so she could get another job that actually paid her when promised.

In the meantime, the therapists at Tidwell, along with counselors, nurses and physicians across Idaho, continue to care for those who live in the shadows of life. But little care has been given to the caregivers. They anxiously await a promise to be kept, a promise that has been broken again and again.